tbuckley/cabot-search huggingface dataset:
P57 Retrospective review of patients with lentigo maligna treated with topical 5% imiquimod (Aldara®) at a single tertiary UK centre: need for more practical standardized treatment guidelines in the UK
Authors: Pavan Sambi, Sina Ghadiri, Usamah Afzal, Andrew Muinonen-Martin, Angana Mitra
Journal: British Journal of Dermatology (2023)

Abstract Lentigo maligna (LM) is an in situ melanoma arising on chronically sun-damaged skin predominantly on the head and neck. While surgery is the gold standard treatment for LM, imiquimod 5%, which is an immune-response modifier, is a well-reported off-licence treatment in both primary and adjuvant settings. Various treatment regimens have been published. We present our retrospective experience of using imiquimod to treat LM over 10 years at a UK tertiary melanoma centre. We report on indications, treatment regimes, side-effects and treatment efficacy. We identified 71 patients with LM treated with imiquimod with a mean age at diagnosis of 73.3 years. Ninety-three per cent were located on the head and neck. Forty-three per cent (n = 29/67) of patients were treated primarily (following punch biopsy diagnosis or incomplete excision with visible pigmentation remaining) and 57% (n = 38/67) with adjuvant treatment (excision with narrow or close margins, &amp;lt; 3 mm with no visible pigmentation). Invasive disease was seen in 17% of those treated primarily and 45% treated with adjuvant therapy. There were various treatment regimens, but the majority (55%) had treatment prescribed five times weekly for 11–12 weeks, with no significant difference in treatment regimens between the two treatment groups. Inflammation was recorded as none (20%), mild (21%), moderate (21%) and severe (20%). Side-effects were redness (40%), pain (17%), ulceration (7%) and systemic symptoms (6%). Fifty-nine per cent of the primary group had visible clearance; a previous study reported a 71% clinical response in this cohort. Three of the responders relapsed, with two progressing to LM melanoma within 8 years. Forty-eight per cent remained disease free, with a mean follow-up of 27 months. Of those treated with adjuvant therapy, 89% remained clinically disease free at mean follow-up of 19 months. Recurrence in the adjuvant group was reported as 5.6% (Lallas A, Moscarella E, Kittler H et al. Real-world experience of off-label use of imiquimod 5% as an adjuvant therapy after surgery or as a monotherapy for lentigo maligna. Br J Dermatol 2021; 185:675–7). Our limitations include a lack of post treatment biopsies. In 2021, an Australian study reported a practical guide on the use of imiquimod for LM (Guitera P, Waddell A, Paton E et al. A practical guide on the use of imiquimod cream to treat lentigo maligna. Australas J Dermatol 2021; 62:478–85). We propose the need for clearer UK guidelines describing the escalation and de-escalation of treatment in the event of no response and toxicity, respectively. We suggest using a patient application diary to ensure compliance and document changes in treatment and inflammation.
P21 Facial papules in an immunocompromised patient
Authors: Kieran Carty, Karen Eustace, Eoghan de Barra
Journal: British Journal of Dermatology (2023)

Abstract A 29-year-old man presented with a 6-week history of clustered facial papules. Of note, he had a diagnosis of HIV 5 months previously and was on maintenance antiretroviral treatment. His initial CD4 count was 5, which increased to 38, and his viral load was now no longer detectable. He had also been treated for cytomegalovirus reactivation, pneumocystis pneumonia and suspected mycobacterium infection for the previous 3 months. He had ongoing symptoms of malaise, fevers, weight loss and nausea, along with abnormal liver function tests and a raised C-reactive protein. A bone marrow trephine showed noncaseating discrete small granulomas; Grocott and periodic acid–Schiff (PAS) stains were negative. Prior to his dermatology review, the papules were initially perioral and he had been treated with empiric valaciclovir for suspected herpes simplex virus (HSV) but with no resolution. Testing for HSV DNA and syphilis was negative. On examination, there were clusters of small nontender, well-circumscribed papules (some umbilicated), distributed on the forehead, cheeks, and cutaneous and mucosal lips. A diagnostic punch biopsy was taken of one of the characteristic papules. Histological examination demonstrated a dense dermal infiltrate of histiocytes with focal non-necrotizing granuloma formation. Interspersed neutrophilic microabscesses and occasional eosinophils were present. PAS stain for fungi confirmed the presence of numerous thick-walled spherules, many with a single distinct nucleus, with some showing binucleation, consistent with fungal organisms located within the histiocytes in the dermis. Differential diagnosis included histoplasmosis, cryptococcosis, blastomycosis and coccidiomycosis. He was commenced on intravenous liposomal amphotericin B for disseminated endemic mycosis while awaiting definitive diagnosis. Formal identification by panfungal polymerase chain reaction of skin tissue was positive for Histoplasma capsulatum and itraconazole was added. The diagnosis was consistent with disseminated histoplasmosis with cutaneous involvement. The lesions resolved completely over 4 weeks, with some residual hyperpigmentation remaining. Histoplasma capsulatum is a dimorphic fungus found in soil and the droppings of bats and birds. Infection is through spore inhalation, with most patients being asymptomatic. It is more prevalent in temperate and tropical climates. Disseminated histoplasmosis occurs mostly in immunocompromised individuals and can be fatal if left untreated. Although endemic to specific world regions, disseminated histoplasmosis should be considered in immunocompromised patients presenting with atypical cutaneous findings, even in regions of low prevalence.
DS22 Pregnancy-associated melanoma: a case series
Authors: Kate Lawlor, Sofia Hadjieconomou, Ruwani Katugampola, Caroline Mills, Vincent Li, Suchitra Rajan
Journal: British Journal of Dermatology (2023)

Abstract There are currently no guidelines in the UK regarding the management of pregnancy-associated melanoma (PAM). It is estimated that one-third of women diagnosed with melanoma are of child-bearing age and numbers are rising (Still R, Brennecke S. Melanoma in pregnancy. Obstet Med 2017; 10:107–12). A recent survey of all dermatologists in our region revealed five cases of PAM. We await the results of a similar survey disseminated to all UK dermatologists. Case 1 was a 22-year-old woman of 16 weeks’ gestation who presented with a 6-week history of a changing mole on her face. Histology confirmed a nodular malignant melanoma [Breslow thickness (BT) 3.5 mm]. A healthy baby was born at full term. Case 2 was a 36-year-old nulliparous woman who presented with a changing lesion on her right calf. Histology confirmed a malignant melanoma (BT 3.6 mm). At the 2-week follow-up, she was 4 weeks pregnant. A healthy baby was born at 38 weeks. Case 3 was a 33-year-old nulliparous woman who had a superficial spreading malignant melanoma (BT 2 mm) excised from her left scapula. Twenty-three months after this diagnosis, pulmonary metastases were evident on computed tomography (CT). Three months later, she became pregnant. A healthy baby was born at term. Case 4 was a 30-year-old nulliparous woman who had a malignant melanoma (BT 3 mm) excised from her right scapula. A sentinel lymph node biopsy (SLNB) was negative, and staging CT showed no evidence of metastatic disease. She received a course of interferon treatment. Three years after initial presentation, at 24 weeks’ gestation, she developed a painful swelling on her right axilla that was confirmed to be metastatic melanoma. A healthy baby was born at 35 weeks. Case 5 was a 27-year-old woman who had a melanocytic lesion that was shave excised by her general practitioner. Subsequent excision confirmed superficial spreading malignant melanoma (BT 1.5 mm, stage 1B). At the time of wide local excision and SLNB 1 month later, the patient was 6/40 gestation. Sentinel lymph node biopsy was negative so no further staging scans were required. A healthy baby was born at term. There are conflicting data on whether PAM carries a poorer prognosis than equivalent disease in nonpregnant women. However, melanoma is one of several cancers that can metastasize to the placenta. Therefore, a diagnosis of PAM complicates decisions regarding staging and treatment (Carter TJ, George C, Harwood C, Nathan P. Melanoma in pregnancy: diagnosis and management in early-stage and advanced disease. Eur J Cancer 2022; 166:240–53).
BT19 Teledermatology preserves the number needed to biopsy for diagnosis of skin cancer
Authors: Thomas Kirwin, Jonathan Kentley
Journal: British Journal of Dermatology (2023)

Abstract In order to ensure a high sensitivity and prevent a missed skin cancer diagnosis, specificity is sacrificed. The number needed to biopsy (NNB) describes the number of benign lesions excised in order to diagnose one skin cancer. Published NNBs are highly variable, but a 2020 meta-analysis reported the overall NNB for melanoma to be 9.6 (Petty AJ, Ackerson B, Garza R et al. Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting. J Am Acad Dermatol 2020; 82:1158–65). The overall NNB is reported to be 3 for any skin cancer and 1.6 for nonmelanoma skin cancer (Matsumoto M, Secrest A, Anderson A et al. Estimating the cost of skin cancer detection by dermatology providers in a large health care system. J Am Acad Dermatol 2018; 78:701–9). The incidence of skin cancer is rising significantly in the UK, placing increased pressures on dermatology departments. A growing body of evidence suggests that the diagnostic accuracy of teledermatology is similar to that of face-to-face (F2F) care and many trusts now employ teledermatology for triage of 2-week wait (2WW) referrals. Our trust uses a teledermatology model where all patients referred via the 2WW pathway complete a digital form with details of the lesion. Both clinical and dermoscopic images are taken by a trained medical photographer and reviewed by a consultant dermatologist. Lesions felt to be suspicious for malignancy are triaged directly for biopsy. We aimed to evaluate the effectiveness of our teledermatology service by calculating the NNB, as well as the number of appointments where a biopsy was not performed following F2F assessment. Over a 2-month period, 251 lesions in 221 patients were triaged for biopsy via teledermatology, and 212 were biopsied following a F2F assessment. Of these, 54 (25.5%) were histologically diagnosed as skin cancer [11 melanoma, nine squamous cell carcinoma (SCC) and 33 basal cell carcinoma (BCC)]. When comparing the teledermatology diagnosis with the histological diagnosis, the overall NNB for skin cancer was 3.9. The NNB varied depending on the type of lesion suspected (7 for melanoma, 7.1 for SCC and 1.6 for BCC). When examining our NNB, it seems the accuracy of our teledermatology service is in keeping with data published from other centres. Furthermore, only a small proportion of lesions (10%) were not biopsied following a F2F assessment, demonstrating that teledermatology probably has a similar accuracy to F2F assessment. Although this is a small study from one centre, it further demonstrates that teledermatology is an efficient use of resources with no clear reduction in diagnostic accuracy.
H23 Traditional healing by skin cauterization (kaiy)
Authors: Atheer Al Haddabi, Emilia Duarte Williamson
Journal: British Journal of Dermatology (2023)

Abstract The practice of kaiy is an ancient medical traditional therapy that is still used in Africa and the Middle East. Kaiy is the Arabic word for cautery; a red-hot iron or coal is placed to the skin. This causes sharp circular, oval or linear burns that are placed in a symmetrical configuration, usually resulting in permanent scars. This practice is undertaken by traditional healers. A Somali woman was referred by her general practitioner to dermatology for an itchy scar on her mid-upper abdomen. She reported that 40 years ago, she had traditional skin cautery therapy to the area for bone pain, which was later diagnosed as rheumatoid arthritis. On examination, she had a 4 × 0.7 cm keloid scar that was treated with a course of KenalogTM injections. This sparked an interest in understanding the practice of kaiy, and a literature review was performed. Cauterization results in the burning of tissue in order to close wounds or stop bleeding. The patient’s symptoms help to decide the location of cauterization. For example, if the presenting complaint is jaundice, the cautery is placed on the left hand. Other medical presentations that kaiy is used for include back pain, headache, depression, chest pain and exorcism. Is this practice useful or are patients being burned for no reason? Historically, it was felt that it was valuable in preventing infection; however, there is no scientific basis for this. The practice was believed to result in the destruction of pathogenic substances within the body due to the extreme heat. Patients who have undergone this therapy report that it gives them short-term relief of their symptoms; this is likely to be due to the release of endogenous opioids, allowing the body to stop the sensation of unremitting pain. Complications are commonly witnessed and consist of deep skin burns, deferred wound healing and secondary wound infections. More serious complications include septic shock, ulceration and viral transmission such as hepatitis B (Farid MK, El-Mansoury A. Kaiy (traditional cautery) in Benghazi, Libya: complications versus effectiveness. Panafr Med J 2015; 22:98; Budair F. Dermatoses due to Arabic cultural and traditional practices. Indian J Dermatol Venereol Leprosy 2019; 85:448–54). Kaiy should be included in the differential diagnosis of a patient presenting with multiple symmetrical scars. Some patients may not be forthcoming in admitting to the treatment if not specifically asked. This presentation aims to increase awareness in dermatologists of this practice.
H08 The <i>Crimson Chronicles</i> of acne rosacea: a fascinating tale of medicine and culture
Authors: Stephanie Adeyemi, Sachi Gupta
Journal: British Journal of Dermatology (2023)

Abstract Acne rosacea is a common skin condition that affects people with Fitzpatrick skin types I–III and is characterized by flushing, erythema, telangiectasia, pustules, papules and phyma (Jansen T. Clinical presentations and classification of rosacea. Ann Dermatol Venereol 2011; 138:3). This condition has been around for centuries and is referred to in literature and art throughout history. The earliest reference to acne rosacea can be traced back to the third century Bc, where it was mentioned in the writings of Greek poet Theocritus. It has also been referred to in various forms of literature, including the character of Summoner in Chaucer’s Canterbury Tales and Bardolf in Shakespeare’s Henry VI (Cribier B. Histoires de visages rouges. Ann Dermatol Venereol 2011; 138:2). In art, the condition is famously depicted in Italian Renaissance painter Domenico Ghirlandaio’s ‘The Old Man and His Grandson’, now housed in the Louvre. The colour red, a prominent characteristic of acne rosacea, has had a significant role in literature, symbolizing everything from love and passion to anger and violence. French novelists Balzac and Proust used it as a motif in ‘The Red Face’ or ‘Le Visage Rouge’ to denote violence and as a marker of the working classes. In the 14th century, French surgeon Guy de Chauliac was the first to document clinically the condition, referring to it as goutterose or ‘pink droplet’. It was in the 18th and 19th centuries that significant strides were made in understanding the nature of acne rosacea. Dr Jean Astruc, known as the father of venereal diseases, characterized the condition as ‘erythematous, varicose and scaly’. In 1812, the official term ‘acne rosacea’ first appeared in a medical text by English dermatologist Dr Thomas Bateman. Further references to the condition can be found in the 1817 publication On Cutaneous Diseases by dermatology pioneer Dr Robert Willan. In 1834, physician Robert Macnish explicitly linked acne rosacea to alcohol consumption in his book Anatomy of Drunkenness. The differentiation between acne vulgaris and acne rosacea was firmly established following the work of Austrian dermatologist Hebra and French dermatologist Darier. In the past, treatments for acne rosacea included salves containing mercury, sulfur, bull’s blood, blood-letting and leeches. Today, topical and oral antibiotics are the standard treatments, a far cry from the remedies of yesteryear. In conclusion, the history of acne rosacea, which is so much more than just le visage rouge, is a captivating journey that spans centuries, from its earliest references in literature and art to the contemporary understanding and treatment of the condition.
CD02 A retrospective comparison of Chemotechnique Cosmetic series–positive contact allergens with the British Society for Cutaneous Allergy facial series
Authors: Orla McFeely, Emma Byrne, Eoin Storan
Journal: British Journal of Dermatology (2023)

Abstract Patch testing is an important tool in the assessment of facial dermatitis. The cosmetic or facial series of haptens are highly relevant in facial dermatitis. The British Society for Cutaneous Allergy has recently updated the facial series to include the reduced number of 24 haptens. We compared positive allergens found in the Chemotechnique Cosmetic series (60 haptens) with that of the British Society for Cutaneous Allergy (BSCA) facial series. We conducted a retrospective review of patients who were patch tested to the Chemotechnique Cosmetic series over a 30-month period. We recorded and compared positive contact allergens in this series with that of the BSCA facial series. Sixty-three patients were patch tested to the Chemotechnique Cosmetic series over a 30-month period. Twenty-one patients were diagnosed with at least one positive contact allergen. In total, 35 contact allergies were diagnosed. Contact allergen positivity was seen to sorbitan oleate (Span 80; positive rate 4.7%), thimerosal (Merthiolate; positive rate 4.7%), chloroacetamide (positive rate 4.7%), hexahyrdo-1,3,5-tris(2-hydroxyethyl) triazine (Groton BK; positive rate 4.7%), abitol (hydroabietyl alcohol; positive rate 9.5%), benzophenon-3 (Eusolex® 4360, EscalolTM 567, oxybenzone; positive rate 4.7%), sorbitan sesquioleate (positive rate 14.2%), benzyl salicylate (positive rate 9.5%), tert-butyl hydroquinone (positive rate 14.2%), tea tree oil oxidized (positive rate 4.7%), 3-(dimethylamino)-1-propylamine (positive rate 4.7%), Amerchol (positive rate 4.7%), quaternium (positive rate 4.7%), methyldibromo glutaronitrile (MDBGN; positive rate 9.5%), methylisothiazolinone (MI; positive rate 4.7%), sodium metabisulfite (positive rate 28.5%) and gallate mix (positive rate 28.5%). Nine patients (43%) were found to have more than one contact allergy. Five of the positive haptens (Amerchol, quaternium, MDBGN, MI and sodium metabisulfite) are captured within the BSCA standard series but are not found within the BSCA facial series. Benzophenone 3 is captured within the BSCA extra facial series. Five further haptens [sorbitan oleate (Span 80), thimerosal (Merthiolate), chloroacetamide, hexahyrdo-1,3,5-tris(2-hydroxyethyl) triazine (Groton BK) and benzyl salicylate] were captured with the Chemotechnique series. However, these five are not included in the BSCA facial series and would not otherwise have been identified. Seventeen per cent of contact allergies would not have been diagnosed in this study if the BSCA facial series had been applied. This study highlights the variation in positivity seen between the Chemotechnique and BSCA facial series and the potential for missed diagnoses.
BI15 (P16) Cutaneous renal cell carcinoma metastasis with scrofuloderma as the initial presentation of metastatic renal cell carcinoma: a diagnostic challenge
Authors: Rohit Kothari
Journal: British Journal of Dermatology (2023)

Abstract Renal cell carcinoma (RCC) with cutaneous metastasis is uncommon and accounts for approximately 3–5% of metastatic RCC, with an unfavourable prognosis. We present an unusual and difficult case of advanced RCC presenting initially with cutaneous metastasis and scrofuloderma, with identical morphology of the lesions. It also highlights the importance of dermatologists in the early diagnosis and management of such cases. A 50-year-old man presented with gradually progressive, multiple erythematous discharging nodules over the right side of his neck of 3 months’ duration. He described a weight loss of 10 kg, intermittent undocumented fever with headache and two episodes of uninvestigated transient haematuria in the last 6 months. He had received multiple courses of antibiotics without any relief. A skin biopsy and immunohistochemistry confirmed cutaneous RCC metastasis with a primary advanced metastatic left RCC, involving the brain as well. A total left nephrectomy was done and he was started on lenvatinib, everolimus and radiotherapy, following which there was suboptimal response and he started developing similar nodular lesions over the left axilla and chest wall, and a puckered crusted plaque over the left lateral abdomen 1 week post-treatment. Follow-up at 8 weeks revealed a significant response in the neck lesions; however, the new lesions on the left side did not respond, following which a dermatology consultation was sought again. A skin biopsy from the new lesions confirmed scrofuloderma. Tissue polymerase chain reaction and culture were positive for mycobacterium tuberculosis. He was diagnosed as having scrofuloderma and started on daily isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months followed by daily isoniazid and rifampicin for 4 months. Follow-up at 6 months revealed well-healed lesions, and the systemic symptoms and discharge had abated. The cutaneous metastatic lesions had also healed completely. Here, we present an interesting case of cutaneous RCC metastasis with coexisting scrofuloderma as the initial manifestation of an advanced RCC, posing a diagnostic challenge due to similar morphology. On this background, a recurrence of cutaneous metastasis was the first possibility considered for the new skin lesions. The delay in diagnosis led to significant morbidity in our patient, emphasizing the role of early dermatology consultation in the management of such cases. A high index of suspicion for conditions masquerading as cutaneous metastasis, as well as a lower threshold for skin biopsy, may improve the prognosis dramatically.